Complaint Intake Form

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Complainant Information:

Name:

Home Address:

Email Address:

Home Phone:

Cell Phone:

Complaint:

Case Number (if known):

Date of Incident:

Date of Incident:

Location of Incident:

Complaint involves an Allegation of:

Time of Incident

Time of Incident

Nature of Complaint: (e.g. courtesy/rudeness. etc...)

Witness Information:

Witness Name: (1)

Witness Home Phone:

Witness Address:

Witness Cell Phone:

Witness Name: (2)

Witness Home Phone:

Witness Address:

Witness Cell Phone:

Member Information:

Member Name: (1)

Badge Number:

Was the Member in Uniform at the time of the incident?

Yes

No

Was the Member in a marked or unmarked car:

Marked

Unmarked

Member Name: (2)

Badge Number:

Was the Member in Uniform at the time of the incident?

Yes

No

Was the Member in a marked or unmarked car:

Marked

Unmarked

F.S.S. 837.06 Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provide in §775.082 or §775.083